Monday, December 23, 2013

Fat-Shaming, An Ineffective Way of Motivating People to Lose Weight: A Critique of the Strong4Life Campaign - Alicia Zonenshine

Over the past two decades, obesity has made its way to the forefront of our nation’s health issues.  This is not only an issue for the adult population, given that it is estimated that 16.9% of American children between the ages of 2 and 19 years old are obese (1).  There are a number of social consequences of childhood obesity which include increased risk of depression, lower self-esteem, lower self-acceptance, and lower life satisfaction (2). In addition, there are also increased risks for cardiovascular disease and all-cause mortality in those that are overweight during their childhood years (3).  It is well known that an effective intervention is necessary to slow the increasing number of children that are overweight and obese.  A number of interventions have been implemented, yet positive results have yet to be seen. 
            One such intervention that has been implemented in Georgia is called Strong4Life (4).  The focus of this campaign is to “stop sugarcoating,” and be blunt with the people of Georgia to get them to make a positive change and stop childhood obesity.  The campaign includes billboards with pictures of overweight children and sayings such as “Fat prevention begins at home.  And the buffet line,” and “It’s hard to be a little girl if you’re not.” (5)  These billboards have stirred up quite the commotion amongst residents of the Atlanta, Georgia community.  Many feel that such a frank campaign will not be effective in stimulating a constructive change, but instead will further stigmatize the children that are overweight and obese (5).  This may also not be the most effective way to motivate children and their parents to adopt a healthy lifestyle. 
            There are obviously a number of people that believe that this is the most effective way to approach the problem of childhood obesity.  Linda Matzigkeit, vice president of Children’s Healthcare of Atlanta, says, “It has to be harsh.  If it’s not, nobody’s going to listen.” (6)  On the surface, this might seem to be a logical explanation.  However, there is a large body of research that suggests that this is not the most effective mechanism of motivating these youngsters and their parents.  There are a few inherent flaws that are detrimental to the design of this intervention, which include the stigmatization of overweight youth, the use of low self-efficacy messages, and the use of fear as a motivation to get people to do something.  Looking at these more in depth will show the ineffectiveness that this intervention is bound to experience.

Flaw 1: Stigmatizing overweight youth
            The Strong4Life campaign is very centralized on the theory of the Health Belief Model.  The Health Belief Model is based on the thought that there are four motivating factors to a person's actions: perceived susceptibility, perceived severity, perceived benefits of an action, and perceived barriers to taking that action (7).  While in theory this seems to make sense from a health perspective, there are a number of reasons why this limits the scope of the Strong4Life campaign.  This model does not apply well to long-term interventions; it is only really effective when it is a one-time thing that you are trying to motivate people to do (8).  This obviously is not promising when applied to a program where the main intended outcome is weight loss.  This model also assumes that the person is in a vacuum and is not influenced by other people, and that people’s actions are reasoned and planned.  In addition, a major assumption that is made is that people value their health more than other things.  This assumption is made in the Strong4Life campaign, and it is definitely one of the bigger flaws of the program (8).  With this program, they are assuming that the parents, who are the intended audience, care more about the health of their children than the freedom to live as they want.  Even though many of the parents of overweight and obese children obviously do care about the health of their children, threatening to take away their freedom to eat and live as they want is more frightening than taking away their health.
            In addition to utilizing the Health Belief Model, the ads and commercials used for the Strong4Life campaign show images of overweight and obese children in a negative semblance.  The billboard ads in particular consist of pictures of overweight youth written over with a bold red “WARNING” label with things such as “Chubby kids may not outlive their parents” written underneath (5).  Overweight and obese youths and adults already deal with so much negative energy in other aspects of their lives that this is only distressing them more.  In a study by Sutin and Terracciano, it was shown that weight discrimination is associated with factors that can cause obesity, including excessive caloric intake and lack of physical activity (2).  They found that for the participants that were not obese at baseline, those that were exposed to weight discrimination were 2.5 times more likely to become obese by follow-up, which was 4 years later (2).  This demonstrates how negative language such as the words “fat” and “chubby” are only further demoralizing these children and their parents.  Not only are these ads stigmatizing overweight and obese children, they are causing more anxiety and perpetuating the problems that these kids are already having to deal with.  Other studies have shown that stigmatizing weight may worsen such medical conditions as hypertension, cortisol reactivity and also the risk for hypertension (9).  By branding these children with words such as "fat," these ads are likely promoting the risk for further psychological and physical health problems.
Flaw #2: Lack of self-efficacy-inducing motivation
            The negativity that these ads bring about not only defames those that are supposed to be helped by them, but also they do not allow for any self-efficacy to be shaped.  How effective can a campaign truly be when it is not motivating and instead is giving its target audience the feeling that they have already lost their battle?  The messages that these ads embody go against the Social Cognitive Theory, which focuses on self-efficacy, or the belief that you are able to do something (10).  This theory explains the fact that self-efficacy has a large impact on both motivation and action (10).  The negativity that these ads put forth does not allow the children and parents that see these ads to achieve a feeling of self-efficacy.  They are essentially knocking these children down and telling them that they have already failed.  If these children believe that they have already failed and that being healthy and losing weight are out of their reach, they are not going to be motivated to change and try to achieve these things.  They will not believe that they can lose weight, join a sports team, or even live a healthy life.  Social Cognitive Theory also takes into account that the environment, individual and the behavior can all influence one another (11).  With that being said, if the environment that is being created is so negative and puts these children down, that is not going to influence the individual or the behavior in a positive manner.  Most likely, the behavior will be viewed negatively, and the individual will not feel as if they are capable to, nor will they want to, do the behavior that the ads are trying to induce.
            The lack of self-efficacy created by these ads goes past merely affecting the children that are being targeted.  These ads are also placing blame on the parents of these overweight and obese children.  One ad in particular features a child that is overweight, with the wording, "He has his father's eyes, his laugh, and maybe even his diabetes." (12)  Not only does this ad make the parents feel as if they have failed their child, but also it is sending a message to the child that it is his or her parent's fault that he or she is overweight.  Thinking about this in the terms of the Social Cognitive Theory, this is creating the same negative environment for the parents, who are supposed to be the intended audience of these ads.  Blaming the parents is inherently saying that they have done something wrong and that they are "bad" parents for letting their children get to the unhealthy state that they are in.  This most likely is going to create a sense of defensiveness for the parents, causing them to not want to listen to these ads.  Overall, these ads have the same effect as they do on the children, not allowing for self-efficacy or the feeling that losing weight and living a healthier lifestyle is achievable. 

Flaw #3: Trying to scare the fat out of people
The frame that this campaign is using is centered around the health consequences of being overweight.  Despite the fact that for most people health is extremely important, as was mentioned before people are known to not make decisions rationally.  As with the Health Belief Model, this is an assumption that many other models used by public health campaigns make (8).  Because people are inherently irrational in their decision making, using a frame that is focused on health is not always the strongest motivator.  Moreover, the way in which this campaign is framed is very negative.  It is presenting the issue in terms of the loss of health that these children are encountering.  Presenting an issue with what there is to lose is going to be far less effective than if it is presented in the form of what there is to be obtained.  It is also known that although in some situations fear may be a good motivator, it is not always so (13).  As reported in a meta-analysis by Witte and Allen, if a campaign is using fear as a motivational tactic, it should be used in conjunction with a high-efficacy message.  If fear is used alongside a low-efficacy message, such as is used by the Strong4Life campaign, there is a higher chance that the response is going to be more defensive and do the opposite of what is intended (13).  Although fear can be an effective way of motivating people to do something, the use of fear needs to be used properly in order get the desired effects.
The fear devices that the Strong4Life campaign uses can also be related to the Psychological Reactance Theory.  This theory states that if certain behaviors are threatened with eradication, the person affected will be motivated to fight for that freedom by however they feel fit (14).  This generally results in the person clinging even more strongly to the threatened belief (15).  In this case, by creating such a shocking ad and threatening the freedom of choice that every American citizen values, the ads are really generating a reactance that will cause the viewers to hold on to that freedom.  Most likely this will manifest in the form of continuing with the lifestyle choices that they are currently making.  This therefore compounds the effect of using stigmatizing and low self-efficacy messages.  Essentially, these ads have potential to do the exact opposite of what the campaign has set out to do. 
            It is fairly clear that using a scare technique in the Strong4Life campaign has its downfalls, yet there is another obstacle related to this that is not addressed by the ads and commercials.  This is the fact that the majority of parents of overweight and obese children do not recognize that their child is at an unhealthy weight (16).  There are a few hypotheses as to why parents do not recognize when their child's weight is an issue, including ethnicity, the gender of the child, and the weight status of the parents (17).  This may also be related to the Law of Optimism Bias, which states that people tend to underestimate their personal risk of something happening to them even when they overestimate the risk of that event happening to the general public (18).  The combination of parents not recognizing that their child is overweight and believing that their child is not at a high risk for developing the negative health outcomes outlined in the ads and commercials makes for an unsuccessful intervention.

Alternative Intervention
            In taking a closer look at the Strong4Life campaign, it has become obvious that there are a number of innate flaws that need to be addressed.  In order to do this, a new program should be put into place.  It would be easiest to start over, reframing the message and painting the picture in a more positive style.  The specifics of this proposed intervention are outlined in the following sections.

Positivity matters
            A big problem with the Strong4Life campaign which was outlined above is that it stigmatizes the overweight youth that it targets.  For this new proposed intervention, billboards will be used but instead of showing one overweight child they will feature a number of different people.  There will be some showing families, including those who are overweight or obese, spending time together.  All of the people in the ad will be happy and smiling.  Other ads will feature groups of children playing sports together or even just being outside together, but also having a good time doing so.  The purpose of these ads will be to get the children to join the movement to become healthier.  To do this, there will be messages written at the bottom of the billboards such as, "Join in the movement!" and "Let's move together!"  By having groups of children or families on the billboards, this takes away the stigmatizing factor of having just one overweight child on the billboard covered with negative words.  These new billboards will create a sense of community and they will target both the parents and children.  This will make joining the movement more like joining a group, making the participants feel as if they are a part of something positive.  There will be a website listed on the ads as well, so that those who want to become a part of the change will have resources that will help them to do so.  On this website, participants will also have the option to get certain merchandise.  Having things such as t-shirts or bracelets with the movement logo on it will allow those involved to feel even more a part of the group.  This can create a sense of ownership, which in this case would be the feeling that one owns the idea of being healthy (19).  One successful anti-smoking campaign that has used this technique is The 8ighty 4our, which targets youth that do not smoke and has essentially created a community of people that are proud of not smoking (20).  Using this approach for losing weight and getting healthy can create a feeling of attachment to the idea of being healthy, and should motivate people to not only work hard at achieving that goal but to also hold it closer with the more work that they put towards living a healthy lifestyle (19).  Presenting eating healthy and exercising more in this manner will allow the children and their parents to see these ads and respond to them in a more positive fashion.  

Induce self-efficacy
            Along with creating a more positive message for the youth and their parents that are the target audience of this new proposed campaign, using messages that more strongly promote self-efficacy will be employed.  The billboards that target more of the youth audience should still feature children that are overweight or obese so that those viewing the ads will be able to relate to them.  However the messages will be things such as a group of kids playing a sport, for instance basketball.  This will show the viewers that they are capable of being athletic and that they should not be afraid to join a sports team.  A child that sees this ad and is motivated to try a sport that they were previously too intimidated to try may be able to become more active and gain more self-esteem, which are positive changes all around.  In order to also target the parents through this campaign, some billboards should feature pictures of families engaging in physical activity together, or even cooking with healthy foods together.  This should have the same effect of promoting self-efficacy for the parents, showing them that it is possible to make positive changes for their families and that it is important to work together to achieve these goals.  In doing this, it is also allowing for both the parents and children to feel a sense of responsibility, instead of placing blame on the parents for causing their children to be unhealthy.

Re-framing the message
            Rather than using scare tactics to motivate people to get healthy, it would be beneficial for this new proposed campaign to focus on something different than merely health.  A more effective way to frame this message would be to use freedom as a core value.  This can be used by framing being healthy and active as a way to express one’s freedom and ability to do whatever he or she aspires to do.  This is related to the ads inducing self-efficacy; they should make people inspired and make them desire to live their lives as the people depicted in the billboards do.   Moreover, by reframing the intervention in order to entice people to join the movement, the fear tactics need not be used.  As was discussed, using fear as a motivator does not always work, and has to be used with higher self-efficacy messages (13).  This new ad campaign will eliminate the need for the use of fear as a motivator, focusing solely on the positive that can come from adopting healthy behaviors. 
            Another approach that will be used to target both parents and children is to use people that are overweight or obese in the billboards, but to present them more positively.  It has been shown that people are more likely to be swayed by someone that is similar to them rather than someone who is different (21).  By using adults that are overweight, the intended audience of the parents will be more likely to agree with the message and be encouraged to join the movement.  The same goes for the children if kids that are overweight are featured in the billboards, the targeted audience of overweight and obese kids will be more likely to listen to the message that the ad is putting forth.  In addition, by presenting this demographic in a more positive way, there will hopefully be less social stigma around weight.  This could potentially help to ease some of the social and psychological anxiety that many overweight and obese children experience.

            It has become increasingly evident that childhood obesity is an enormous problem in the United States and around the world.  Developing an appropriate intervention to help stop the increasing numbers of overweight and obese children throughout the world is extremely important.  Obese children are known to have an increased risk of cardiovascular disease and all-cause mortality than those children that are of normal weight (3).  In addition to these physical health risks, overweight and obese children have a higher risk of psychological issues such as depression, low self-esteem and self-acceptance as well as lower life satisfaction in general (2).  If something is not done to successfully slow and eventually stop this trend, the entire planet will be dealing with excessive health problems that we may not necessarily be equipped to deal with.
            Many interventions have been attempted in vain, including the Strong4Life campaign.  The flaws of this campaign were highlighted in this critique and were based on a number of different behavioral and social theories.  Specifically, those used to analyze the Strong4Life campaign were the Health Belief Model, Social Cognitive Theory, Framing Theory, Psychological Reactance Theory and the Law of Optimism Bias.  By using these different theories, it was determined that the Strong4Life campaign, which includes billboard ads and a few commercials featuring similar messages, is inherently flawed based on a few different reasons.  These flaws were centered on the stigmatization of overweight youth, the use of low self-efficacy messages, and the use of scare tactics.  In determining these flaws, a new intervention has been proposed which is based on the very theories that prove the Strong4Life campaign is unsound.  This new intervention will feature billboard ads that display messages such as “Join in the movement!” over pictures of kids playing sports together, or families cooking healthy meals together.  There will be no negative images of any person, child or adult, and there will be no blaming of any particular person.  Further information will be available at the website provided on the billboard where a person will be able to get further information on how to get healthy, as well as purchase items such as t-shirts or bracelets that exhibit the movement logo.  By being positive and showing kids and parents that they are capable of achieving a healthy lifestyle, this crusade will embody higher self-efficacy, a sense of ownership and commitment, as well as a sense of community.  These different methods, when used in conjunction, will hopefully aid in the fight against childhood obesity.

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